From today’s news: “Backup presidential limo on its way for Obama in Israel after fuel filling failure.”
U.S. President Barack Obama’s trip to Israel was tripped up by a preventable error – the Presidential limousine was mistakenly filled with diesel fuel instead of gasoline / petrol.
One of the limousines in Barack Obama’s fleet has broken after reports that it was mistakenly filled with the wrong fuel at the start of the US president’s visit to Israel.
Another limo is on its way from Jordan, according to Ma’an News agency, citing Israel’s Channel 10, to replace one that was filled with diesel instead of gasolene.
This is clearly a preventable error… one that could increase the risk of harm to the President if the vehicle broke down in an unsafe location. I’m curious to hear if there will be any “root cause analysis” and corrective actions taken to prevent a future re-occurrence (or somebody will just be punished).
In the U.S., diesel fuel nozzles at the pump are intentionally LARGER than nozzles for unleaded gasoline. This serves as a form of mistake proofing, or error proofing (read more at Professor John Grout’s excellent mistakeproofing.com website). It’s a bigger mess (without destroying the engine, though) when you mistakenly put diesel in a car that runs on unleaded gas than it would be vice versa… which is why it’s generally not as well error proofed against mistakenly putting unleaded into a diesel. BMW, though, has a system to prevent you from putting gas into a diesel.
Apparently having a larger diesel nozzle isn’t the case in all countries — perhaps including Israel? Or was this just a problem at the location where the limo was fueled up?
Mistake proofing (“poka yoke” in Japanese) is a core part of the “Lean” management system and improvement methodology, tracing back to days before Toyota made cars. The term “jidoka” (automation with a human touch) traces back to Toyota’s innovations with weaving looms that stop automatically when a thread breaks. This stops the production of bad fabric and saves a lot of worker time that would be spent cleaning up after the problem.
Hospitals are increasingly using Lean and mistake proofing techniques to prevent errors such as wrong site surgeries or giving the wrong medication (or dose) to patients. You can read about this in Chapter 8 of my book Lean Hospitals and you can also get a free PDF on healthcare mistake proofing from Prof. Grout.
Mistake proofing is more effective than signs that tell people to “be more careful.” If an error CAN occur, it might not happen every day, but it’s basically inevitable when a person with an otherwise perfect track record has a bad day… as happened with the limo.
About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. Mark is also the VP of Customer Success for the technology company KaiNexus. He lives in San Antonio, Texas.